Post by Amtram on Mar 9, 2014 10:34:16 GMT -5

Dr. Shaili Jain, blogging at PLoS, put up a great post about the fundamentals of treating psychiatric patients based on a presentation she was giving to Nurse Practitioners, and in response to a New York Times article about teaching doctors how to diagnose and treat ADHD more effectively. I think it's an important thing for all of us to be aware of. We go to our doctors expecting that they will know what to do and will take care of us, but not much beyond that. For that reason, we aren't able to advocate for ourselves if we're not certain that we're getting the best standard of care.

I want to look at each of the points she directed towards physicians, and turn them around to us, the patients. If we know what our doctors should be doing, and we know how to help them help us, it works out to better results for everyone. Here are her commandments, and how I feel we need to be integrated into them:#1. Thou Shalt Always Aim To Establish And Maintain A Therapeutic Alliance - Dr. Jain explains the importance of building a relationship with the patient that's based on "collaboration, trust, and mutual respect." One of the things I've heard far too often from this side of the doctor-patient relationship is that the doctor is not listening, or is dismissing our concerns about symptoms or treatment, or leaving us feeling marginalized of objectified. It's good to know that you, as a patient, are entitled to this. If you're not getting it, you need a different doctor.

#2. Thou Shalt Always Do A Complete Psychiatric Assessment - We know about the revolving-door technique. A good doctor looks into all the possible factors in our illness, both in the present and in the past.

#3. Thou Shalt Always Do A Thorough Evaluation For Safety - Here, Dr. Jain focuses mostly on evaluating the signs that a patient may be suicidal or pose a threat to others, but she also includes looking for signs of potentially dangerous impulsive behaviors and inability to care for dependents. My own experience has been that these questions were always covered (well, except for once or twice early on in my treatments) but I've heard so many stories from people whose ability to care for themselves and others was dismissed to believe it should be obvious.

#4. Thou Shalt Always Identify the Appropriate Treatment Setting - Yes, there are times when hospitalization is the best option. If your doctor recommends it, there's probably a good reason, and it's nothing to be ashamed of.

#5. Thou Shalt Focus On The Patient’s Functional Impairment And Quality Of Life - We all know about this, right? The impact of our disorder is what makes it a disorder and not just something that "everybody has a little" of. Dr. Jain wants physicians to understand the impact of the illness on all areas of our lives when making decisions about treatment. We don't need medications for school or work; we need treatments that reduce the impact of our impairments on all areas of our lives. We're allowed to tell our doctors that a treatment is having a negative effect on our quality of life that outweighs the effect on individual symptoms, and request a re-evaluation of our treatment because of it.

#6. Thou Shalt Coordinate The Patient’s Care With Other Clinicians - Unfortunately, this is something that's difficult for doctors to do on their own. We need to make sure that our doctors all know what our other doctors are doing. If we can see different doctors that have professional relations with one another, that's great - but nearly impossible in our current system. We, as patients, need to inform our doctors of all the names and contact information of all our specialists, and keep our records of our prescriptions current with all of them. We also need to ask the doctors who are prescribing for us to help us find any additional care we might need. That could be psychological counseling, speech therapy, occupational therapy, or even seeing a different specialist physician.

#7. Thou Shalt Monitor The Patient’s Psychiatric Status - We should be seeing the doctor fairly frequently if we are new to treatment or are changing treatments, and if the doctor isn't asking us specific questions about our responses to the treatment in detail, we need to be prepared to provide it. Is it causing changes in appetite, weight, or digestion? Is it having an effect on personality or mood that isn't acceptable? Are we experiencing problems with involuntary movement or sleep or speech? The doctor should be asking these questions, but many issues that crop up with medication can be unusual or rare enough that the doctor might not think to ask. We need to make note of these and inform our physicians so they can treat us properly.

#8. Thou Shalt Integrate Measurements Into Psychiatric Management - How many of you have re-taken the questionnaires that were given to you when you were initially evaluated? Taking them again after your treatment has stabilized is a good way to measure the progress and effectiveness of treatment, both for you and your doctor.

#9. Thou Shalt Evaluate A Patient’s Treatment Adherence - The doctor should be asking you if you're complying with the treatment regimen. Don't lie to your doctor about this. The reason you're not following treatment instructions is important to making sure that your treatment is effective.

#10. Thou Shalt Provide Education To The Patient And Their Family - This is a difficult one. Different doctors have different areas of expertise, and might not have the resources to educate their patients or patients' families on adjunct issues. If we want to educate ourselves, then we're forced to wade through a huge amount of misinformation and speculation to find reality-based answers. One of the goals of this community is to provide access to information that's backed up by science, which is why the posts so far have been heavy on links. If you have questions, you should always check with your physician first, and if he refers your question to a different specialist, listen to that practitioner as well.

Post by Amtram on Mar 10, 2014 22:43:52 GMT -5

Dr. Jain wanted to clarify one thing from what I wrote above. I didn't remember how clear I had been, and after looking at it, I think the best way to elaborate is to share what she said:

This is my view: Re: step 1, I would emphasize that “collaboration, trust, and mutual respect.” between dr and patient is a two way street. The doctor has the primary duties and responsibilities to set the tone and treatment frame, of course, but it is very helpful when patients are open and transparent in their communication too.

Also, I think it’s unrealistic to expect the relationship to be “perfect”; these are serious issues we are dealing with and, whenever important goals are being accomplished, there will be ups and downs in the relationship. Sometimes doctors have to be the bad guy and say things that need to be said and not sugarcoat things. As long as the doctor acts professionally and respectfully whilst doing this, I don’t see it as a bad thing.

I agree. There are a lot of things that can influence that relationship that have as much to do with us as patients as they do with our doctors' performance. We need to be realistic about our needs and expectations, and make the decision about whether we actually need to see another doctor based on more than just dissatisfaction. I think on some of the other points I mentioned being honest with your doctor and complying and communicating, but those are important in regards to the first item as well.